Abstract:

Organ transplantation, one of the most remarkable achievements of modern medicine, is deeply rooted in definitions of death that are both medically complex and ethically contested. This narrative review explores how brain death and the dead donor rule (DDR) have shaped the practice of organ procurement, while also highlighting persistent controversies that continue to challenge clinicians, policymakers, and ethicists. Through a review of 56 peer-reviewed publications, we examine the variability in brain death determination, advances in donor management, and the promising emergence of Donation after Circulatory Determination of Death (DCDD).

The findings of our review reveal significant inconsistencies in diagnostic criteria across institutions and jurisdictions, which not only undermine public trust but also create uncertainty at the bedside. The implementation of standardized donor management strategies, despite their potential to improve graft survival and increase organ yield, remains uneven. The expansion of the donor pool through DCDD is a positive development, but the less favorable outcomes, particularly for thoracic organs, raise ethical concerns. This underscores the urgent need for standardization in the field of organ transplantation.

The DDR remains a cornerstone principle, defended as essential for maintaining trust but challenged by scholars who argue it represents a social and legal construct rather than a biological truth. International comparisons highlight the cultural dimensions of these debates: Spain exemplifies the effectiveness of coordinated systems and public engagement, whereas Japan illustrates the challenges posed by cultural resistance to brain-death criteria.

Keywords: Brain death, dead donor rule, organ transplantation ethics, donation after circulatory death (DCDD), donor management